1
|
Inchingolo F, Inchingolo AM, Piras F, Ferrante L, Mancini A, Palermo A, Inchingolo AD, Dipalma G. Management of Patients Receiving Anticoagulation Therapy in Dental Practice: A Systematic Review. Healthcare (Basel) 2024; 12:1537. [PMID: 39120240 PMCID: PMC11311453 DOI: 10.3390/healthcare12151537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/22/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Anticoagulant drugs are a valuable tool for minimizing thrombotic risks in at-risk patients. The purpose of this study is to conduct a literature review highlighting the management of these drugs during daily clinical dental practice. MATERIALS AND METHODS We limited our search to English-language papers published between 1 January 1989, and 7 March 2024, in PubMed, Scopus and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "anticoagulant AND dentistry" were used. RESULTS Twenty-five clinical trials were included for final review from 623 articles obtained from the databases Web of Science (83), PubMed (382), and Scopus (158), eliminating duplicates and 79 off-topic items, resulting in 419 articles after removing 315 entries and confirming eligibility. Overall, these studies support the use of local hemostatic measures to manage the risk of bleeding in patients on anticoagulant therapy undergoing dental procedures and highlight the importance of greater education and collaboration among healthcare professionals. CONCLUSIONS Research and clinical investigation have improved understanding and management of dental procedures in patients undergoing anticoagulant or antiplatelet therapy. Hemostatic agents, clinical protocols, risk factors, and continuous education are essential for navigating the complexities of anticoagulant therapy, ensuring optimal outcomes and enhancing patient well-being.
Collapse
Affiliation(s)
- Francesco Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Angelo Michele Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Fabio Piras
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Laura Ferrante
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Antonio Mancini
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Andrea Palermo
- College of Medicine and Dentistry, Birmingham B4 6BN, UK;
| | - Alessio Danilo Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| | - Gianna Dipalma
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy or (A.M.I.); or (L.F.); or (A.M.); or (A.D.I.); or (G.D.)
| |
Collapse
|
2
|
Darwish G. The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review. BMC Oral Health 2023; 23:743. [PMID: 37821865 PMCID: PMC10566068 DOI: 10.1186/s12903-023-03427-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) were developed to overcome the drawbacks of oral anticoagulants. However, not much has been discussed about the perioperative management of patients on DOACs during oral surgical procedures. Thus, we aim to determine the risk of perioperative and postoperative bleeding during oral surgical procedures in patients on DOACs. METHODS A detailed literature search was performed to find potentially relevant studies using the Cochrane Library, Clinical Key, ClinicalTrials.gov, Google Scholar, Ovid, ScienceDirect, and Scopus. Every article available for free in English literature for the past 10 years, between 2012 and 2022, was searched. RESULTS A total of 2792 abstracts were selected through a search strategy across various search engines. Based on inclusion and exclusion criteria, eleven clinical studies using DOACs as anticoagulants or studies comparing patients with and without DOACs under oral surgery procedures were found. The results were inconsistent and varied, with a few studies recommending DOAC administration with the bare minimum reported complications and others finding no statistically significant difference between discontinuation or continuation of drugs, especially across basic dental procedures. CONCLUSION Within the limitations of the study, it can be concluded that minor oral surgical procedures are safe for patients on DOAC therapy. However, the continuation or discontinuation of DOACs in patients undergoing oral surgical procedures remains controversial and requires further studies to extrapolate the results.
Collapse
Affiliation(s)
- Ghassan Darwish
- Department of Oral and Maxillofacial Surgery, School of Dentistry, King Abdulaziz University, 21589, Jeddah, Saudi Arabia.
| |
Collapse
|
3
|
Campana MD, Aliberti A, Acerra A, Sammartino P, Dolce P, Sammartino G, Gasparro R. The Effectiveness and Safety of Autologous Platelet Concentrates as Hemostatic Agents after Tooth Extraction in Patients on Anticoagulant Therapy: A Systematic Review of Randomized, Controlled Trials. J Clin Med 2023; 12:5342. [PMID: 37629387 PMCID: PMC10455824 DOI: 10.3390/jcm12165342] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/25/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
One of the common challenges in oral surgery is dealing with patients who are taking oral anticoagulant/antiaggregant drugs. Several local hemostatic agents have been proposed as an alternative to conventional suturing. Among these, autologous platelet concentrates (APCs) have been widely used to decrease the risk of hemorrhage after dental extraction. Nevertheless, there is a lack of consensus regarding the superiority of any one specific hemostatic agent over the others. This systematic review is aimed at evaluating the effectiveness of APCs as hemostatic agents after tooth extraction in patients on anticoagulant therapy. A literature search was conducted of articles published before March 2023 on PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). Studies on the use of APCs in patients undergoing dental extractions and being treated with anticoagulant drugs were included. Only randomized, controlled trials (RCTs) published up to March 2023 were included; the outcomes assessed were the time to hemostasis, the presence of post-operative bleeding and pain, and the effectiveness of wound healing. The risk of bias for each RCT was assessed by using the 'risk of bias' tool (RoB 1.0). The research revealed 6 RCTs. The findings indicated that patients on anticoagulant therapy who received APCs without discontinuing their medication experienced a decreased post-operative bleeding, a shorter hemostasis time, reduced pain, and accelerated wound healing. However, due to the high/unclear risk of bias of the studies included, no definitive conclusions can be drawn on the superiority of APCs as hemostatic agents over other similar products. Additional studies are required to validate these findings.
Collapse
Affiliation(s)
- Maria Domenica Campana
- Department of Neurosciences, Reproductive Sciences and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (M.D.C.); (A.A.); (A.A.); (R.G.)
| | - Angelo Aliberti
- Department of Neurosciences, Reproductive Sciences and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (M.D.C.); (A.A.); (A.A.); (R.G.)
| | - Alfonso Acerra
- Department of Neurosciences, Reproductive Sciences and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (M.D.C.); (A.A.); (A.A.); (R.G.)
| | - Pasquale Sammartino
- Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy;
| | - Pasquale Dolce
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy;
| | - Gilberto Sammartino
- Department of Neurosciences, Reproductive Sciences and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (M.D.C.); (A.A.); (A.A.); (R.G.)
| | - Roberta Gasparro
- Department of Neurosciences, Reproductive Sciences and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (M.D.C.); (A.A.); (A.A.); (R.G.)
| |
Collapse
|
4
|
Bacci C, Schiazzano C, Zanon E, Stellini E, Sbricoli L. Bleeding Disorders and Dental Implants: Review and Clinical Indications. J Clin Med 2023; 12:4757. [PMID: 37510872 PMCID: PMC10380778 DOI: 10.3390/jcm12144757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians. MATERIAL AND METHODS Pubmed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis. RESULTS Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication. CONCLUSION Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.
Collapse
Affiliation(s)
- Christian Bacci
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Claudia Schiazzano
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35128 Padua, Italy
| | - Edoardo Stellini
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Luca Sbricoli
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| |
Collapse
|
5
|
Johansson K, Götrick B, Holst J, Tranæus S, Naimi-Akbar A. Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:333-346. [PMID: 36100547 DOI: 10.1016/j.oooo.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications. STUDY DESIGN The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined. RESULTS Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients. CONCLUSIONS Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.
Collapse
Affiliation(s)
- Krister Johansson
- Department of Oral and Maxillofacial Surgery and Oral Medicine, Faculty of Odontology, Malmö University, Malmö, Sweden.
| | - Bengt Götrick
- Department of Oral Diagnostics, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Jan Holst
- Department of Vascular Diseases and HTA Syd, Skåne University Hospital, Malmö/Lund, Sweden
| | - Sofia Tranæus
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Aron Naimi-Akbar
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
| |
Collapse
|
6
|
Zou L, Hua L. Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis. Acta Odontol Scand 2023; 81:98-104. [PMID: 35763663 DOI: 10.1080/00016357.2022.2085324] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A large number of patients under oral anticoagulant (OAC) or antiplatelet (AP) therapy require dental implantation. We systematically reviewed evidence on the risk of bleeding after implant placement with continued OAC or AP therapy. METHODS PubMed, Embase and CENTRAL were searched for studies comparing bleeding outcomes after implant placement between OAC/AP therapy vs. controls or OAC vs. AP therapy. RESULTS Seven studies were included. Pooled analysis showed no significant difference in the risk of bleeding with continued OAC therapy vs. control (RR 1.81 95% confidence interval [CI] 0.70, 4.63 I2 = 14% p = .22). Subgroup analysis depending on the type of OAC showed there was a non-significant tendency of increased risk of bleeding with Vitamin K antagonists (VKAs) (RR 3.42 95% CI 1.00, 11.67 I2 = 23% p = .05) but not with direct oral anticoagulants (DOACs) (RR 1.67 95% CI 0.49, 5.70 I2 = 0% p = .41). Limited data suggest an increased risk of bleeding with OAC as compared to AP (RR 0.08 95% CI 0.01, 0.76 I2 = 0% p = .03). CONCLUSIONS Continuation of OAC therapy in patients undergoing implant surgery does not increase the risk of bleeding provided local haemostatic measures are used. The indirect comparison suggests bleeding tendency may be higher with VKAs as compared to DOAC.
Collapse
Affiliation(s)
- Lilin Zou
- Department of Stomatology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, PR China
| | - Li Hua
- Department of Stomatology, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| |
Collapse
|
7
|
Inokoshi M, Soeda Y, Akiyama Y, Ueda K, Kubota K, Minakuchi S. Fully Digital Workflow for the Fabrication of Three-Dimensionally Printed Surgical Splints for Preventing Postoperative Bleeding: A Case Report. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12773. [PMID: 36232073 PMCID: PMC9566380 DOI: 10.3390/ijerph191912773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
The management of postoperative bleeding is mandatory in patients receiving anticoagulants. In this case report, we introduce a fully digital workflow for surgical splint fabrication to prevent postoperative bleeding in patients receiving anticoagulants and/or at risk of inadvertent extraction of a mobile tooth during impression making. An 87-year-old woman using apixaban had a left mandibular canine that required extraction due to chronic apical periodontitis. A digital impression was obtained using an intraoral scanner. First, the tooth to be extracted was deleted using three-dimensional (3D) computer-aided design (CAD) software (Geomagic Freeform, 3D Systems) and a stereolithography (STL) file was exported. This modified STL file was imported into another CAD software (3Shape Dental System, 3Shape) and a surgical splint was designed. The splint was fabricated using a 3D printer (Form 3; Formlabs) and light-curable resin (Dental LT Clear, Formlabs) and was delivered after the tooth extraction. The patient was followed-up 2 days after the extraction; no postoperative bleeding was detected and the surgical splint was removed. The additively manufactured surgical splint fabricated using a fully digital workflow was efficacious for managing postoperative bleeding after a dental extraction.
Collapse
|
8
|
Psillas G, Dimas GG, Papaioannou D, Savopoulos C, Constantinidis J. Epistaxis in dental and maxillofacial practice: a comprehensive review. J Korean Assoc Oral Maxillofac Surg 2022; 48:13-20. [PMID: 35221303 PMCID: PMC8890961 DOI: 10.5125/jkaoms.2022.48.1.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/05/2021] [Accepted: 04/20/2021] [Indexed: 11/07/2022] Open
Abstract
The lifetime incidence of epistaxis in dental and maxillofacial practice has been reported to be as high as 60% and can be caused by dental implant placement, Le Fort I osteotomy, intranasal supernumerary tooth, odontogenic tumors, blood disorders and maxillofacial trauma. Most epistaxis cases are minor and easily managed with direct compression on the nares for 10 minutes. For more significant or recurrent epistaxis, other techniques might include electrocautery, anterior or posterior nasal packing, or Foley catheter balloon. For patients with refractory epistaxis, cauterization of the sphenopalatine artery under endonasal endoscopy or embolization of the internal maxillary artery should be performed. Epistaxis control is required in patients diagnosed with inherited or acquired bleeding disorders or with drug-induced coagulopathies during dental procedures. In these cases, hemostatic system adjustment and hemostasis achieved by local and adjunctive methods are required. Dentists and maxillofacial surgeons must be aware that the nasal cavity is a potential source of perioperative hemorrhage. Depending on the invasiveness of the dental intervention, preoperative involvement of the hematologist and cardiologist is usually necessary to reverse anticoagulation or to cease anticoagulant therapy.
Collapse
Affiliation(s)
- George Psillas
- 1st Academic ENT Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Grigorios Georgios Dimas
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Despoina Papaioannou
- School of Dentistry, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Jiannis Constantinidis
- 1st Academic ENT Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| |
Collapse
|
9
|
Manfredini M, Poli PP, Creminelli L, Porro A, Maiorana C, Beretta M. Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery. J Clin Med 2021; 10:5526. [PMID: 34884228 PMCID: PMC8658703 DOI: 10.3390/jcm10235526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. MATERIALS AND METHODS A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. RESULTS 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. CONCLUSIONS No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. CLINICAL RELEVANCE direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.
Collapse
Affiliation(s)
| | | | | | - Alberto Porro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Odontostomatology Unit, University of Milan, Via della Commenda 10, 20122 Milan, Italy; (M.M.); (P.P.P.); (L.C.); (C.M.); (M.B.)
| | | | | |
Collapse
|
10
|
Costa-Tort J, Schiavo-Di Flaviano V, González-Navarro B, Jané-Salas E, Estrugo-Devesa A, López-López J. Update on the management of anticoagulated and antiaggregated patients in dental practice: Literature review. J Clin Exp Dent 2021; 13:e948-e956. [PMID: 34603625 PMCID: PMC8464381 DOI: 10.4317/jced.58586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Oral antiplatelet and anticoagulant drugs are widely used in a large number of patients visiting the dentist, and there has been much controversy over the years towards their clinical management. The aim to carry out a literature review in order to develop an update on dental management in anticoagulated and / or anti aggregated patients, focusing on oral surgery.
Material and Methods A bibliographic search was carried out in PubMed on studies published between January 1, 2018, until December 10, 2020, using the keywords (“antiplatelet” OR “antiplatelets”) AND (“dentistry”), and (“anticoagulant” OR “anticoagulants”) AND (“dentistry”).
Results The number of studies included in this review was 13, and the number of patients among all of them was 3.497 patients under treatment with some type of antithrombotic drug, who underwent different oral surgery treatments.
Conclusions There is a low risk of peri- and postoperative bleeding events during basic oral surgery treatments in antiplatelet or anticoagulated patients, which can be easily managed through the use of local haemostatic measures. Key words:Oral surgery, antiplatelet drugs, anticoagulant drugs, dental treatment.
Collapse
Affiliation(s)
- Jesús Costa-Tort
- DDS, Master's student. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Verónica Schiavo-Di Flaviano
- DDS, Master's degree. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Beatriz González-Navarro
- DDS, Professor of Master's degree. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Enric Jané-Salas
- PhD, DDS, MD. Professor of Oral Pathology. Department of Odontostomatology. Faculty of Medicine and Health Sciences (Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Estrugo-Devesa
- PhD, DDS, MD. Professor of Oral Pathology. Department of Odontostomatology. Faculty of Medicine and Health Sciences (Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José López-López
- DDS, MD, PhD, Department of Odontoestomatology. Faculty of Medicine and Health Sciences (School of Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain. / Dental Hospital University of Barcelona, (Barcelona University) / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, Barcelona, Spain
| |
Collapse
|
11
|
Aminoshariae A, Donaldson M, Horan M, Kulild JC, Baur D. Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques. J Endod 2021; 47:1557-1565. [PMID: 34265324 DOI: 10.1016/j.joen.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this study was to review evidence-based recommendations for the safe perioperative management of patients undergoing endodontic microsurgery who are currently taking antiplatelet or anticoagulant medications. Using the PICO (Population, Intervention, Comparison, Outcome) format, the following scientific question was asked: In patients taking anticoagulant or antiplatelet agents, what is the available evidence in the management of endodontic microsurgery? METHODS MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched to identify current recommendations regarding the management of antiplatelet and anticoagulant medications in the context of outpatient dental surgical procedures. Additionally, the authors hand searched the bibliographies of all relevant articles, the gray literature, and textbooks. Because of the lack of clinical studies and evidence on this subject, articles and guidelines from other organizations and association position statements were included. RESULTS Because any minor surgery can become a major surgery, the treating doctor needs to best assess the risk of bleeding, especially if the surgery is anticipated to take longer than 45 minutes. Every patient should be stratified on a case-by-case basis. Consultation with the patient's physician is highly recommended. CONCLUSIONS In order to maximize the effects of these medications (to prevent thrombosis) while minimizing the potential risks (procedural hemorrhage), clinicians should be aware of the best available evidence when considering continuation or discontinuation of antiplatelet and anticoagulant agents perioperatively for endodontic microsurgery. Ideally, a joint effort from an expert panel for microsurgery would be warranted.
Collapse
Affiliation(s)
- Anita Aminoshariae
- Departments of Endodontics, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio.
| | - Mark Donaldson
- School of Pharmacy, University of Montana, Missoula, Montana; School of Dentistry, Oregon Health and Sciences University, Portland, Oregon
| | - Michael Horan
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
| | - James C Kulild
- UKMC Dental School, University of Missouri-Kansas City, Kansas City, Missouri
| | - Dale Baur
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
| |
Collapse
|
12
|
Bleeding Complications in Anticoagulated and/or Antiplatelet-Treated Patients at the Dental Office: A Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041609. [PMID: 33567762 PMCID: PMC7915452 DOI: 10.3390/ijerph18041609] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bleeding complications in patients undergoing antiplatelet and/or anticoagulant therapy have been one of the main concerns in dental practice. Upon the introduction of new antiplatelet and anticoagulant drugs, there is a search for new protocols that respond to a secure treatment. The aim of the present study was to evaluate bleeding complications in anticoagulated and antiplatelet-treated patients after performing simple dental extractions, in a period of 4 years. MATERIAL AND METHODS 147 clinical records of anticoagulated and/or antiplatelet-treated patients undergoing a simple dental extraction over a period of 4 years (October 2015 to September 2019) were studied. Within the sample, 63 patients were antiplatelet-treated, 83 were anticoagulated, and 1 patient was under both therapies. Within the anticoagulated patients, 70 took classic anticoagulants and 14 new oral anticoagulants (NOACs). Quantitative data were studied with arithmetic mean and standard deviation (SD). The chi-square test was used for the qualitative variables. ANOVA tests were used to compare age and anticoagulated or antiplatelet-treated patients. Statistical significance was determined when p < 0.05. RESULTS From the 418 dental extractions performed, five severe bleeding complications took place in three patients (2.11%). From the five events, four were in patients treated with NOACs (1.68%) and one occurred in a patient anticoagulated with acenocoumarol (0.42%; p = 0.003). CONCLUSIONS Considering the results of this retrospective clinical study, we can conclude that bleeding complications in anticoagulated and/or antiplatelet-treated patients after tooth extractions were low, with a higher incidence recorded in patients treated with NOACs, followed by classic anticoagulants, and there were no complications in antiplatelet-treated patients.
Collapse
|
13
|
Bajkin BV, Wahl MJ, Miller CS. Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:522-532. [DOI: 10.1016/j.oooo.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
|
14
|
Inokoshi M, Kubota K, Yamaga E, Ueda K, Minakuchi S. Postoperative bleeding after dental extraction among elderly patients under anticoagulant therapy. Clin Oral Investig 2020; 25:2363-2371. [PMID: 32875384 DOI: 10.1007/s00784-020-03559-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study aimed to assess and compare postoperative bleeding occurrence after dental extraction in medically compromised elderly patients under anticoagulant therapy. MATERIALS AND METHODS This retrospective study included medically compromised elderly patients aged ≥ 65 years who were taking apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin and had undergone single or multiple dental extractions. The primary outcome measure was postoperative bleeding occurrence, which was defined as oozing or marked hemorrhage from 24 h to 7 days after dental extraction. Postoperative bleeding occurrence was calculated for each anticoagulant and compared using Fisher's exact test, followed by multiple comparisons. RESULTS Two hundred thirty-two patients met the inclusion criteria. The highest postoperative bleeding occurrence was recorded for rivaroxaban (12/37: 32.4%), followed by apixaban (8/44: 18.2%), warfarin (17/98: 17.3%), and edoxaban (2/35: 5.7%). Patients taking dabigatran did not present postoperative bleeding (0/18: 0%). Fisher's exact test, followed by multiple comparison tests, revealed a significant among-anticoagulant difference (p = 0.0095). Postoperative bleeding was significantly higher in patients taking rivaroxaban than in those taking edoxaban or dabigatran (p = 0.03088). CONCLUSIONS Within the limitations of this retrospective study design, these findings suggest that different anticoagulants may affect postoperative bleeding occurrence after dental extraction among medically compromised elderly patients. CLINICAL RELEVANCE Clinicians should carefully consider postoperative bleeding after dental extraction in patients taking anticoagulant therapy, especially rivaroxaban.
Collapse
Affiliation(s)
- Masanao Inokoshi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Kazumasa Kubota
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan.
| | - Eijiro Yamaga
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Kaori Ueda
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Shunsuke Minakuchi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| |
Collapse
|
15
|
Sanz M, Marco del Castillo A, Jepsen S, Gonzalez‐Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel J, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol 2020; 47:268-288. [PMID: 32011025 PMCID: PMC7027895 DOI: 10.1111/jcpe.13189] [Citation(s) in RCA: 612] [Impact Index Per Article: 153.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/13/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. MATERIAL AND METHODS There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations RESULTS AND CONCLUSIONS: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
Collapse
Affiliation(s)
- Mariano Sanz
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Søren Jepsen
- Department of Periodontology, Operative and Preventive DentistryUniversity of BonnBonnGermany
| | - Jose R. Gonzalez‐Juanatey
- Cardiology DepartmentUniversity HospitalIDISCIBERCVUniverity of Santiago de CompostelaSantiago de CompostelaSpain
| | - Francesco D’Aiuto
- Department of PeriodontologyEastman Dental Institute and HospitalUniversity College LondonLondonUK
| | - Philippe Bouchard
- U.F.R. d'odontologieUniversité Paris DiderotHôpital Rothschild AP‐HPParisFrance
| | - Iain Chapple
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Thomas Dietrich
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Israel Gotsman
- Heart InstituteHadassah University HospitalJerusalemIsrael
| | - Filippo Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care MedicineUniversity of PisaPisaItaly
| | - David Herrera
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Phoebus Madianos
- Department of PeriodontologySchool of DentistryNational and Kapodistrian University of AthensAthensGreece
| | - Jean‐Baptiste Michel
- Inserm Unit 1148Laboratory for Translational CV ScienceX. Bichat HospitalParisFrance
| | - Pablo Perel
- World Heart FederationGenevaSwitzerland
- Centre for Global Chronic ConditionsLondon School of Hygiene & Tropical MedicineLondonUK
| | - Burkert Pieske
- Department of Internal Medicin & CardiologyCharité Universitätsmedizin BerlinBerlinGermany
- DZHK (German Center for Cardiovascular Research) Partnersite BerlinGerman Heart Institut BerlinBerlinGermany
| | - Lior Shapira
- Department of PeriodontologyHebrew University – Hadassah Faculty of Dental MedicineJerusalemIsrael
| | - Michael Shechter
- Leviev Heart CenterChaim Sheba Medical Centertel Hashomer and the Sackler Faculty of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Maurizio Tonetti
- Department of PeriodontologyPrince Philip Dental HospitalThe University of Hong KongHong KongHong Kong
| | | | - Gernot Wimmer
- Department of Prosthetic DentistrySchool of Dental MedicineKarl‐Franzens University GrazGrazAustria
| |
Collapse
|
16
|
Sanz M, del Castillo AM, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel JB, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and Cardiovascular Diseases. Consensus Report. Glob Heart 2020; 15:1. [PMID: 32489774 PMCID: PMC7218770 DOI: 10.5334/gh.400] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. Material and Methods There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. Results and Conclusions The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
Collapse
Affiliation(s)
- M. Sanz
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | | | - S. Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, DE
| | - J. R. Gonzalez-Juanatey
- Cardiology Department, University Hospital, University of Santiago de Compostela, IDIS, CIBERCV, ES
| | - F. D’Aiuto
- Department of Periodontology, Eastman Dental Institute and Hospital, University College London, London, UK
| | - P. Bouchard
- U.F.R. d’odontologie, Université Paris Diderot, Hôpital Rothschild AP-HP, Paris, FR
| | - I. Chapple
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - T. Dietrich
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - I. Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, IL
| | - F. Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, IT
| | - D. Herrera
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | - B. Loos
- ACTA University, Amsterdam, NL
| | - P. Madianos
- Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, GR
| | - J. B. Michel
- Inserm Unit 1148, laboratory for translational CV science, X. Bichat hospital, Paris, FR
| | - P. Perel
- World Heart Federation, Geneva, CH
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, UK
| | - B. Pieske
- Charité Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology, Berlin, DE
- DZHK (German Center for Cardiovascular Research) Partnersite Berlin, German Heart Institut Berlin, DE
| | - L. Shapira
- Department of Periodontology, Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, IL
| | - M. Shechter
- Leviev Heart Center, Chaim Sheba Medical Center, tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, IL
| | - M. Tonetti
- Department of Periodontology, The University of Hong Kong, Prince Philip Dental Hospital, HK
| | - C. Vlachopoulos
- Department of Cardiology, National and Kapodistrian University of Athens, GR
| | - G. Wimmer
- Department of Prosthetic Dentistry, School of Dental Medicine, Karl-Franzens University Graz, AT
| |
Collapse
|
17
|
Rubino RT, Dawson DR, Kryscio RJ, Al-Sabbagh M, Miller CS. Postoperative bleeding associated with antiplatelet and anticoagulant drugs: A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:243-249. [DOI: 10.1016/j.oooo.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/21/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022]
|
18
|
Manfredi M, Dave B, Percudani D, Christoforou J, Karasneh J, Diz Dios P, Glick M, Kumar N, Lockhart PB, Patton LL. World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta‐analysis. Oral Dis 2019; 25 Suppl 1:157-173. [DOI: 10.1111/odi.13086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Affiliation(s)
| | - Bella Dave
- Department of Oral MedicineLeeds Dental Institute Leeds West Yorkshire UK
| | | | | | - Jumana Karasneh
- Department of Oral Medicine and SurgeryFaculty of DentistryJordan University of Science and Technology Irbid Jordan
| | - Pedro Diz Dios
- Medical‐Surgical Dentistry Research Group (OMEQUI)Health Research Institute of Santiago de Compostela (IDIS)University of Santiago de Compostela Santiago de Compostela Spain
| | - Michael Glick
- School of Dental MedicineUniversity at Buffalo, The State University of New York Buffalo New York
| | - Navdeep Kumar
- Cert Surg & Pros ImplantologyEastman Dental Hospital for Oral Healthcare Sciences London UK
| | | | | |
Collapse
|
19
|
Paravattil B, Elewa H. Approaches to Direct Oral Anticoagulant Selection in Practice. J Cardiovasc Pharmacol Ther 2018; 24:1074248418793137. [PMID: 30092658 DOI: 10.1177/1074248418793137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Direct oral anticoagulants (DOACs) carry many advantages over warfarin and are now considered first line or an alternative for mnay thromboembolic disorders. With the emergence of 5 DOAC agents to the market as well as the accumulating evidence gathered from head-to-head comparisons between the agents, we attempt to provide direction for clinicians when selecting the most appropriate DOAC agent. Important aspects such as efficacy, safety, cost effectiveness, approved indications, and other drug-related factors will be addressed to highlight the major similarities and diversities among the DOACs. When considering the safety profile of DOACs, evidence points toward apixaban as the safest followed by dabigatran and then rivaroxaban. On the other hand, dabigatran currently has the only approved antidote, idarucizumab. According to the approved DOAC indications, rivaroxaban may be favorable in European countries given its additional indication for secondary prevention of myocardial infarction. Following rivaroxaban, dabigatran and apixaban have the largest number of approved indications and lastly comes edoxaban and then betrixaban. For patients with renal impairment, betrixaban is the safest option, followed by apixaban and edoxaban, then rivaroxaban and lastly dabigatran. When considering DOAC dosing, rivaroxaban, edoxaban, and betrixaban are mainly dosed once daily compared to dabigatran and apixaban, which are dosed twice daily. However, rivaroxaban and betrixaban must be administered with food, which adds another level of complexity to the DOAC dosing. Lastly, taking into consideration drug interactions, dabigatran, edoxaban, and betrixaban have the least amount of interactions compared to apixaban and rivaroxaban. Each DOAC has its own set of features that makes it better suited than others based on the exact clinical situation. Therefore, no conclusion can be drawn to the most superior DOAC based on the aspects discussed in this review.
Collapse
Affiliation(s)
- Bridget Paravattil
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Hazem Elewa
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| |
Collapse
|